TBL 15

Contraception
Group 5b- Putrajaya
DEFINITION/OVERVIEW OF
CONTRACEPTION
● Contraception is the prevention of
pregnancy.
● On an individual basis it is important to
ensure that all pregnancies are wanted or
intended.
● It is also important on a global scale because
the world population is rapidly increasing.
● Millions of women worldwide would prefer to
delay or avoid pregnancy but, unfortunately,
lack access to safe and eective
contraception.
● Contraceptive methods also help reduce the
spread of disease due to, human
immunodeficiency virus (HIV) and Chlamydia.
The ideal contraceptive does not exist, but would have the characteristics
below:

● Eicacy of contraception
● Safety of contraception
● Compliance with contraception
● Special patient groups:-

- Contraception for the adolescent

- Contraception in women with inflammatory bowel disease (IBD)
- Contraception in breastfeeding women
- Contraception in later life
- Contraception in the developing world
Classification & types
of contraception
Natural family planning
Cervical mucus Symptothermal
Calendar method
method method
● Record length of 6
● Requires sensing & ● Temperature record
observing the cervical before geing out of
cycles
mucus changes bed
● Estimate the
● During ovulation ● Progesterone
beginning of fertile
mucus becomes secretion is
period by -18 days
opaque,sticky and associated with rise in
from the length of
much less stretchy or basal body
shortest cycle
disappear all together temperature (0.5c)
● Estimate end of fertile
● Intercourse is ● Prior to ovulation
period by -11 days from
permied beginning temperature usually
longest cycle
on the 4th day after below normal body
last day of sticky wet temperature
mucus
Natural family planning
Lactational Coitus
Amenorrhea Interruptus

● When a baby suckles

● Penis is taken out of
frequently of the
the vagina and
breast hormones
ejaculate outside the
released that disrupts
vagina to try prevent
normal paern of
pregnancy.
GnRH release by the
hypothalamus, ● The goal is to keep
interrupts a woman’s
sperm from entering
normal ovulation cycle
the vagina
by prevent LH surge
 Medical intervention
Combined OPC Progesterone
(COCP) only pills (POP)
● Combination of ethynil estradiol + ● Types of POP
progesterone ○ Etynodiol diacetate 500mcg
● Ethynil estradiol 15-35 Microgram (femulen)
● Types of progesterone ○ Norethisterone
○ Second generation 350mcg(noriday)
■ Norethisterone 1mg ○ Levonorgestrel 30mcg
■ Levonorgestrel 150mcg ○ Norgestrel 75mcg
○ Third generation ○ Desogestrel(cerazee)
■ Desogestrel 150mcg
■ Gestodene 150mcg
■ Norgestimate 250mcg
Medical implants
Intrauterine
Implants
devices (IUD)
● Implanon
● Copper IUD ○ Single, rod implant biodegradable
○ Lasted for 5 years/10 years ○ Release progesterone
etonogestrel 25–70 mg daily
○ Should be removed after
○ Inserted subdermally in the groove
menopause between bicep and tricep in
○ Eectiveness;FR 0.8% woman dominant hand
per year. ○ Can be administered up to 5 of
● MIRENA - levonogestrel hormone menses without the need for the
additional contraception
releasing IUS ○ License for three years
○ Licensed for five years ● Norplant- levonogestrel implant
○ For heavy bleeding patients ○ Release a low-dose levonogestrel
○ Eectiveness; FR 0.1% woman at the rate of 30–35mcg/24 hours
per year.
 Barrier method

Male condom Female condom

● Latex condom ● Diaphragm

○ -Eectiveness: failure rate is 2-5 per 100 ● Cervical cap(femcap)

women per year
● Reasons of failure
● Sponge
Condom completely unrolled into penis
○
○ Slippage when penis withdraw from vagina ● Spermicide
or during sexual intercourse
○ Breakage – due to use of oil-based
lubricants
○ Mechanical-puncture of condom
 Sterilization
Vasectomy Tubal ligation
● Blocks or cuts vas deferens tube,keeping ● Bilateral Tubal Ligation (BTL)- a surgical
sperm out of your semen procedure that involves blocking the
● Advised to use contraception until
fallopian tubes to prevent the ovum (egg)
from being fertilized. It can be done by
azoospermia confirmed
cuing, burning or removing sections of
the fallopian tubes or by placing clips on
each tube
 USAGE OF
CONTRACEPTION
Mechanisms of action
Spermicide Kills sperm

Male Condom, Female Condom, Cervical Cap Physical barrier preventing sperm from
reaching the ovum

COCP (Combined oral contraceptive pill) 1. Inhibit ovulation

- By preventing of ovarian follicular
maturation
- By interrupting oestrogen-mediated
positive feedback on the hypothalamic –
pituitary axis thus preventing LH surge
2. Thicken the cervical mucus
- Decrease sperm penetrability (inability to
reach the ovum)
3. Alteration of the endometrium
- Stabilization and thinning of the
endometrium which decrease the
likelihood of implantation
POP (Progesterone only pill) 1. Thicken cervical mucus
- Decrease sperm penetrability (inability to
reach the ovum)
2. Suppress ovulation
- Cause irregular menstrual cycle
3. A reduction in the number and size of
endometrial glands leading to an atrophic
endometrium not suitable for ovum
implantation
4. A reduction in cilia motility in the fallopian
tube, thus slowing the rate of ovum
transport

Injectable Contraception 1. Inhibit ovulation by preventing of LH

surge
2. Affect cervical mucus thickening and
causing endometrium to be not
favourable for implantation

Sterilization Intended permanent sterilization (completed

family)
Implants 1. Inhibit ovulation by preventing of LH
surge
2. Affect cervical mucus thickening and
causing endometrium to be not
favourable for implantation

IUD 1. Copper IUD

- Toxic to both sperm and ovum
2. Intrauterine System (IUS)
- Release progesterone hormone causing
hormonal effect on the cervical mucus
and endometrium
Timing of usage of contraception
Spermicide Used together with condom, or cervical cap

Male Condom, Female Condom, Cervical Cap Use before Intercourse

COCP (Combined oral contraceptive pill) - Start on 2nd day of menstruation

- Take 1 pill every day of 21 days
- Followed by 7 days of pill free period
- Taken at the same time every day
(maintain constant hormonal level)

POP (Progesterone only pill) - Take one pill everyday taken on the first
day of cycle
- Taken continuously without break
- Must take at the same time every day

Implants 1. Implanon
- Etonogestrel implant (3 years)
2. Norplant
- Levonorgestrel implant (6 capsules to be
use for 5 years)
Injection Contraception 1. Depo-provera
- Progestrone only
- Every 3 months +/- 2 weeks
2. Noristerat
- Combined
- Administered every 2 months +/- 2 weeks

Emergency Contraception Within 3 days (72 Hours)

1. If presented within 72H
- High Dose OCP (2 pills taken 12H apart)
- POP (2 pills taken 12H apart
2. Presented after 72H
- Copper IUD

IUD 1. Copper IUD

- 5/10 Years
2. Intrauterine System
- 5 Years

Sterilization After completed a family

 ADVANTAGES AND
DISADVANTAGES OF
EACH METHODS OF
CONTRACEPTION
 01

NATURAL METHOD
 ADVANTAGES DISADVANTAGES

RHYTHM METHOD ● Free of charge ● Not the most reliable way of preventing pregnancy
- Calendar ● No side effects ● Difficult to calculate the safe period reliably
rhythm ● Needs several months training to use these methods
- Temperature ● Compulsory abstinence from sexual act during certain periods
rhythm ● Not applicable during lactational amenorrhea or when the
- Mucus rhythm periods are irregular
● Failure rate 8-25%

Coitus interruptus ● Free of charge ● Requires sufficient self-control by the man (variable
(Withdrawal) ● Safe for breastfeeding if effectiveness as it depends on the willingness and ability to
the method is used withdraw)
correctly ● The woman may develop anxiety neurosis, vaginismus or
pelvic congestion
● Does not protect against STDs
● Chance of pregnancy is more:
- Precoital secretion may contain sperm
- Accidental chance of sperm deposition into the vagina
 02

BARRIER METHOD
 ADVANTAGES DISADVANTAGES

MALE ● Cheap ● Possibility to tear or slip off during coitus

CONDOM ● Easy to use & easily available ● Allergic reaction (latex)
● Prevents unplanned pregnancy ● Lacks sensitivity around glans of penis
● Protects against STDs ● Mechanical damage from fingernails

FEMALE ● Prevents unplanned pregnancy ● Requires practice to use it

CONDOM ● Protects against STDs and PID ● Outside ring may slip into the vagina during intercourse
● Can be used multiple times with washing, ● May cause discomfort and vagial irritation
drying and with lubrication ● Not easily available as male condom
● Expensive

SPERMICIDAL ● Simple to use ● In isolation, it is not effective but enhances the efficacy of
● Available in various types ( vaginal condom or diaphragm when used along with it.
foams, gels, creams, tablet ) ● Protects against some STDs but not known against HIV

DIAPHRAGM & ● Protect against some STDs ● Ill-fitting and accidental displacement during intercourse
CERVICAL CAP increase the failure rate
● Requires practice to use it & consultation from medical
personnel to determine the right size
● May increase incidence of urinary tract infection
● Needs proper care as it has to be washed and cleaned
afterward used & requires careful storage
 03

MEDICAL METHOD
 ADVANTAGES DISADVANTAGES

COCP ● Protection against unwanted pregnancy (Low ● Requires education and motivation
failure rate) ● Requires initial checkup and periodic supervision
● Highly effective ● Inconvenience caused in its use due to daily schedule
● Well-tolerated in majority ● Risk of drug interactions
● Good cycle control ● Minor complications: nausea, vomiting, headache, leg
● Reversibility rate is prompt cramps, mastalgia, weight gain,
● Reduces dysmenorrhea, menorrhagia, PMS,
Mittelschmerz syndrome & IDA
● Prevents endometrial ca, epithelial ovarian
ca and colorectal ca

Progestrin ● No adverse effect on lactation ● May be acne, mastalgia, headache, breakthrough

Only pills ● Easy to take as there is no “on and off” bleeding, or at times amenorrhea
regime ● Failure rate is about 0.5–2 per 100 women
● May be prescribed in patient having (medical ● Simple cysts of the ovary may be seen, but they do
disorders) hypertension, fibroid, diabetes, not require any surgery
epilepsy, smoking and history of
thromboembolism
● Reduces the risk of PID and endometrial ca
 ADVANTAGES DISADVANTAGES

IUCDs ● Simplicity in techniques of insertion ● Adverse local reactions manifested by

● Prolonged contraceptive protection after menstrual abnormalities, PID, pelvic pain,
insertion (5–10 years) and suitable for the rural syncopal attack and heavy periods. ( less side
population of developing countries effects with third generation of IUDs)
● Suitable for hypertensives, breastfeeding women ● Risk of ectopic pregnancy
and epileptics ● Risk of spontaneous expulsion and perforation
● No systemic side effects of uterus
● Reversibility to fertility is prompt after removal
● High efficacy with low failure rate
 04

SURGICAL METHOD
 ADVANTAGES DISADVANTAGES

MALE ● Simple procedure ● Additional contraceptive protection is needed for about 2–3 months
STERILIZATION ● Low fertility rate of 1:2000 in following operations. till the semen becomes free of sperm
comparison to 1:200 in BTL Immediate
● Possibility of success of ● Scrotal Haematoma (1-2%)
reversal anastomosis operation ● Wound infection (up to 5%)
(70–80%) Late
● Can be done under local ● Frigidity or impotency (mostly psychological).
anaesthesia ● Sperm granuloma - dt inflammatory reaction to sperm leakage (prevented
● Relatively cheaper & safer than by cauterization or fulguration of the cut ends)
BTL ● Chronic intrascrotal pain and discomfort (post-vasectomy syndrome) may
● Not associated with prostate ca, be due to scar tissue formation, or tubular distension of the epididymis
testicular ca or heart disease ● Spontaneous recanalization (1 in 2,000) - rare

FEMALE ● Various approach (Abdominal ● Difficult to reverse as it is meant to be a permanent procedure

STERILIZATION approach , vaginal approach , ● Risk of exposure to anaesthetic
mini-lap and laparoscopic ● Surgical complications (complication: 1-4% with BTL)
sterilization
● Low failure rate (0.1-0.5%) General complications:
● Ocasional obesity & psychological upset
Gynecological:
● Chronic pelvic pain
● Menstrual abnormalities in the form of menorrhagia, hypomenorrhea or
irregular periods and dysmenorrhea
● Post-ligation syndrome (pelvic pain, menorrhagia & cystic ovaries)
● Alteration in libido.
 05

EMERGENCY
CONTRACEPTION
 ADVANTAGES DISADVANTAGES

COPPER IUD ● Failure rate 0-1%

● Gold standard for emergency
contraception

PROGESTERONE ● No fetal adverse effects have been ● Nausea & vomiting are much more
RECEPTOR observed when there is failure of intense with estrogen use. - Antiemetic
MODULATORS emergency contraception. (meclizine) should be given
● Induced abortion should be offered to
the patient if the method fails

COMBINED ● Equally effective as other methods ● Oral antiemetic (10 mg

HORMONAL metoclopramide) may be taken to reduce
REGIMEN nausea and vomiting.
MANAGEMENT OF
MISSED PILLS
1) Combined OCP (COCP) 2) Progesterone – only pills
Ethynil estradiol (POP)
+progesteron
Missed more than 3 hours
Missed 1 pill •Take the pill as soon as possible
•Take 1 immediately within 24 hour then take •Take subsequent pills at usual time
all the others as usual •Additional precautions (condom) for 2 days

Missed 2 pills or more If vomiting within 3 hours of dose or severe

•Take 1 immediately within 24 hours then diarrhea
take all the others as usual •Additional precautions (condom) for 7 days
•Add condom for the next 7 days
THANK YOU